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Emergency medicine and critical care medical education blogMon, 02 Mar 2015 13:09:38 +0000en-UShourly1http://wordpress.org/?v=4.1.1LITFL Review 171http://lifeinthefastlane.com/litfl-review-171/
http://lifeinthefastlane.com/litfl-review-171/#respondSun, 01 Mar 2015 23:07:27 +0000http://lifeinthefastlane.com/?p=125580Welcome to the 171th LITFL Review. Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chuck of FOAM. The Most Fair […]

Welcome to the 171th LITFL Review. Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chuck of FOAM.

]]>http://lifeinthefastlane.com/litfl-review-171/feed/0Research and Reviews in the Fastlane 072http://lifeinthefastlane.com/research-and-reviews-in-the-fastlane-072/
http://lifeinthefastlane.com/research-and-reviews-in-the-fastlane-072/#respondWed, 25 Feb 2015 23:08:19 +0000http://lifeinthefastlane.com/?p=123284Welcome to the 72th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature. […]

Welcome to the 72th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

The leading cause of mortality in children is accidental injuries. Fortunately, the majority of kids that you see after injuries will not have severe trauma, but sorting out those who are at risk of serious abdominal trauma can be difficult. This is a reminder that you can rely on your exam… when the child has a normal GCS. As the GCS declines, the reliability of your exam declines as well.

Recommended by Sean Fox

Research and Critical AppraisalSedgwick P. Sample size: how many participants are needed in a cohort study? BMJ. 2014 Oct 31;349:g6557. PMID 25361576

This is really just to highlight the excellent series that Phillip Sedgwick [@statistics_man] writes for the BMJ. Sadly not #FOAMed but a great resource for those looking to learn for the UK FCEM exam. Here’s a link to every single one below.

An excellent, evidence based review of the critical components of RSI. The authors use this evidence to build a standard operating procedure with an airway checklist and kit dump that can aid in building team dynamics and decrease the incidence of adverse events.

We’re taught to administer vasopressors through central lines and this may delay these medications. These authors searched the literature to find extravasation and local tissue complications of vasopressors and came up with case reports (n=305 from 270 patients). They found that local tissue injury attributable to peripheral administration tends to occur in distal IV sites following long durations of infusions (average infusion duration before extravasation: 35.2 h). If a patient needs a pressor, they can get it peripherally temporarily while you’re obtaining central access.

The ATLS shock classification has been taking a beating lately. The classification in it self has very little scientific back up – studies have shown that more than 90% of all trauma patients could not be classified according to system. Irrespective of mechanism of injury the classification it may overestimate the degree of tachycardia associated with hypotension and underestimate mental disability in the presence of hypovolaemic shock. Does the ATLS faculty believe it? – Doesn’t seem so. In a survey among 383 European ATLS course instructors and directors the actual appreciation and confidence in this tool during daily clinical trauma care was assessed. Less than half (48%) of all respondents declared that they use the system in their own practice. Overall it seems that the ATLS shock classification today serves only on purpose – namely to test the students attending the course. Hopefully future ATLS manuals will revise the current classification.

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

Of all the things that emergency physicians do, rapid sequence induction has to be the most sinister.

To paralyse a man, or a woman, or a child, with a lethal serum – and then bring them back, from the point of death, with seconds to spare! With nothing more than a trusty metal blade, held in the left hand, and air blown through a tube!

This is why some have suggested that RSI should also stand for Really Stupid Idea.

Now imagine if something came along, a technological breakthrough, a new machine, that transformed RSI. That made it, well, easy. And safe. Actually, a Really Sensible Idea. How would you feel?

And what would you say if this machine were coming very soon, coming at you – from the near future. In fact – it’s just arrived. And that trusty metal blade that you are holding in your left hand – is now scheduled for termination.

Welcome to the 170th LITFL Review. Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chuck of FOAM.

The Most Fair Dinkum Ripper Beauts of the Week

Rory Spiegel offers an in-depth look at the endovascular study triad recently released (MR CLEAN, EXTEND-IA and ESCAPE) to treat acute ischemic strokes, and why we should be cautiously optimistic that a small subset of patients have been identified in whom this therapy can be greatly beneficial. [AS]

Burnout and psychological illness occur at a significant rate amongst intensivists. Deb Chalmers writes an incredibly thoughtful post reminding us how important it is to look after ourselves. “The flame that burns twice as bright burns half as long”… [SO]

Beautiful images from Ultrasound of the Week #38, with a case of a lady brought in after a road traffic accident. Can you spot the sign? [SO]

Echopraxis.com is a wonderful new critical care echo resource from a bunch of echo-mad intensivists in Australia. It’s brilliant. Why not get started with this post on a lady struggling to get to her letterbox? (thanks to Oli Flower and Adrian Wong for the tip) [SO]

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http://lifeinthefastlane.com/research-reviews-fastlane-071/#commentsWed, 18 Feb 2015 22:22:04 +0000http://lifeinthefastlane.com/?p=123282Research and Reviews (R&R) in the FastLane: experts worldwide tell us what they think is worth reading from emergency medicine and critical care literature

Welcome to the 71st edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

The much awaited PROPPR trial – an enormous logistic accomplishment – successfully randomised 680 severely injured patients to a transfusion strategy of either 1:1:1 or 1:1:2 (plasma:platelets:RBCs) in 12 different level 1 trauma centers. Among these patients there was no significant difference in 24 hour or 30 day mortality when comparing the two strategies. BUT, the study was powered to detect an absolute difference in outcome of 10 %! Just look at the Kaplain-Meier Failure Curves for Mortality – they seem to send a clear signal.

An important pilot study attempting to objectify what we mean when we use the word “gestalt”. Kline and others looked at facial expression variability and their findings suggest a relationship between a lack thereof, and serious disease. While this may not be a shocking finding, it’s an important first step in an attempt to be able to quantify, teach, and possible objectively use this data in the clinical setting. A preliminary study which will hopefully generate further research into this important area of work.

Does IV magnesium have a role in the management of acute migraine headache in the ED? A new study says yes. Compared to dexamethasone + metoclopramide (fair comparator?), magnesium sulfate was more effective in decreasing pain severity at 20-min and 1-h and 2-h intervals after treatment (p < 0.0001).

A comparison of the Glasgow-Blatchford (GBS) and AIMS65 scoring systems in UGIB patients in the ED population found the GBS to be more sensitive and have a higher negative predictive value for needed interventions in the low risk population. Like many studies examining clinical decision tools and scoring instruments, it was unfortunately not compared to the clinician’s prediction of expected clinical course, or gestalt. A well done study comparing the two scores, and important for ED providers to be aware of, nonetheless.

Despite sparse evidence of long-term outcome improvement in pediatric patients, cognitive rest, coupled with physical rest and graduated return to play, is the mainstay of concussion treatment and recommended by major societies. How strict this “rest” should be is debatable, but this RCT in patients age 11-22 showed no benefit in short term outcomes from “strict” rest versus usual care (varied, but 1-2 days rest and then graduated return to activities). This contribution suggests that restrictions (no school, work, or physical activity) patients feel from strict rest may engender more emotional symptoms than general rest. Prescribe rest to patients and make sure they follow up, but maybe we don’t have to be quite so strict.

Findings from transesophageal echocardiography during CPR suggest that narrowing of the base of left ventricle and of the aorta root may be an indicator of quality of chest compressions. This small case series analyse 6 patients with non-traumatic cardiac arrest using transthoracic US to evaluate the possibility to check the efficacy of chest compressions and to guide changes of hands position in order to improve heart contractility. In 3 out of 6 cases chest compressions were deemed not satisfactory and changes of hands positions guided by US subsequently improved the quality of chest compressions. In the other 3 cases the compression of left ventricle was deemed good and no changes were made. Importantly all US examinations were conducted without interferences with normal standard of care. The authors state that these observations indicate that changes of hands position guided by US could improve the quality of CPR and this area deserves attention and consideration in the future.

Procedural sedation & analgesia for intra oral procedures (IOP) such as lacerations, I&D and aspirations is generally considered with a higher risk of Serious Adverse Events During Sedation (SAEDS). This papers compares 38 cases (sedation for IOP) with 41 controls (sedation for forearm fracture reduction) in terms of SAEDS (apnea, hypoxemia (oximetry <93%), hypoventilation, laryngospasmand other upper airway obstruction). Both groups have similar sedation strategies and events; 5 hypoxic/2 apneas in cases vs. 4 hypoxic/2 apneas in control. This papers appears to show that IOP have similar risk of SAEDS compared to sedation for non IOP procedures.

Duty hour rules and regulations are pervasive in US medical training. This study looks at the effect of institution of duty hour restrictions on the outcome of Medicare patients. Although the study is retrospective and derived from large database information, it gives us a peak into the bigger picture of duty hours regulations: patient outcomes. The study authors found no difference in any important outcomes. It is similarly unclear whether these restrictions have improved resident quality of education or quality of life. Large system wide changes duty hour restrictions should, in the future, be implemented not based on theory but actual data of improved outcomes. An accompanying editorial delves into this issue and others.

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

Welcome to the 169th LITFL Review. Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chuck of FOAM.

Excellent Paucis Verbis (PV) card for just in time reminder for POC echocardiography from ALiEM. [AS]

Has the time for clot retrieval devices in the care of acute ischemic stroke finally come to pass? Ryan Radecki takes a great look at the recent lit and controversial use for carefully selected patients. [AS]

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http://lifeinthefastlane.com/research-reviews-fastlane-070/#respondWed, 11 Feb 2015 20:57:22 +0000http://lifeinthefastlane.com/?p=123280Research and Reviews (R&R) in the FastLane: experts worldwide tell us what they think is worth reading from emergency medicine and critical care literature

Welcome to the 70th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This Edition’s R&R Hall of Famer

A number of studies demonstrate the utility of POC US for the diagnosis of pneumonia. This study demonstrated a high sensitivity (86%) and very high specificity (97%) when looking for consolidations > 1 cm on US compared to chest X-ray as the standard. The study was done quickly (mean 7 minutes) and by non-experts (1 hour of training) increasing the likelihood that the findings can be generalized to non-study settings.

Recommended by: Anand Swaminathan

The Best of the Rest

After introduction of mechanical CPR device CPR induced consciousness seems more prevalent. Though CPR induced consciousness may be distressing for the rescuers (and maybe the patient) it is often percieved as a good prognostic sign of outcome. The current guidelines on advanced cardiopulmonary resuscitation focus on delivering high quality chest compressions with minimal interruptions only pausing for rhythm check or if the patient shows signs of life. Thus CPR induced consciousness may be mistanken for signs of life interupting the sequence of CPR and influence the quality of care. This systematic review only identified reports on 10 patients. The incidence, implications and prognostic value of CPR-induced consciousness remains unknown and should be eveluated.

The use of TXA in severe trauma is current standard practice, but its benefit in Peds trauma is not clear. This study is a retrospective review of TXA use in pediatric civilian victims managed by NATO in Afghanistan. From 766 patients, 66 received TXA; this patients had severe torso or extremity trauma. The TXA group was significantly sicker than control (ISS 18 vs 10). The unadjusted mortality was not statically significant but higher in the TXA group (15 vs 8%), however the severity adjusted mortality was lower in TXA with an OR 0.27; with no adverse events. The study has several limitations, particularly a relatively low number of events and the differences between TXA and control (being the TXA way sicker), but appears to show TXA is beneficial is severe pediatric trauma.

Should we delay neurosurgical intervention in patients with traumatic intracranial bleeds due to slight INR elevations? This study looks at the delays that occur from mild elevations and found that patients with INR < 1.4 had their neurosurgical intervention 174 minutes earlier on average than those with an elevated INR. Additionally, they found that mild INR elevations were not correlated with abnormal coagulation based on TEG measurement. Although patient outcomes were not a primary outcome, this study should make us reconsider the utility of INR and delayed intervention based on it.

A retrospective observational study which examines the link between opioid prescriptions given in the ED to opioid naive patients (as defined by no filled rx in the past year) and opioid use one year later. A well done study which used the state prescription monitoring program to determine opioid use, and found an important link between filled ED prescriptions and later use. An adjusted odds ratio of 1.8 for recurrent use was found. Limited by the design of the study, this is still important information for ED providers as we consider the implications of providing opioids to our patients for their acute pain issues.

This RCT compared amoxicillin-clavulanate with placebo in children 6mo – 15 years old with acute otitis media (AOM) (n=84). The authors conclude “antimicrobial treatment of AOM in children is beneficial because it significantly reduces the duration of Middle Ear Effusion (MEE).” These findings seemingly contradict the AAP and Cochrane recommendations against antibiotics for most cases of AOM. Why? The primary and secondary outcomes were not clinically relevant, MEE and time to improved tympanogram findings, respectively. Let’s stop looking for small improvement in surrogate measures, particularly when the intervention (antibiotics) is associated with harm (NNH 1 in 9 for diarrhea).

The evolution of laryngoscopy began with devices designed to maximally displace the tongue and other soft tissues of the mouth to establish a direct line of sight between the operator’s eye and the patient’s glottis. Video laryngoscopy allows for less tissue displacement, by eliminating the need for direct line of sight, but because of the distance between the camera and the tip of the blade, and the absence of a channel for delivering the ETT, varying degrees of tissue displacement is still needed. The authors of this paper developed a laryngoscope shaped to follow the curve of the airway, with an ETT channel and the camera mounted at the tip of the blade, which allows for visualization of the glottis and delivery of the tube without tissue displacement. It worked extremely well in this small manikin study, though the failure rates they report with other devices are incongruous with the rest of the literature and undermine face validity. I am also concerned about how this device will perform with soiled airways, common in EM. Though this paper only describes a prototype, this may be the shape of things to come in laryngoscopy.

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

]]>http://lifeinthefastlane.com/research-reviews-fastlane-070/feed/0Saving the Healthcare Dollarhttp://lifeinthefastlane.com/saving-healthcare-dollar/
http://lifeinthefastlane.com/saving-healthcare-dollar/#commentsWed, 11 Feb 2015 03:00:46 +0000http://lifeinthefastlane.com/?p=123782The cost of healthcare is rising. Expensive treatments, long life expectancy and the ageing population are pressuring the Healthcare Dollar

The cost of healthcare is rising. New and expensive treatments, longer life expectancy and an ageing population are developing into a tsunami which threatens to flatten the health budget of first world economies.

At the coalface in the emergency department we are being told by our hospital administrators that the health budget cuts must be passed on. We are to find increased productivity and efficiency with no increase in staffing numbers – in fact staff must be cut to achieve budgets constraints. Do more with less staff is the message being received in emergency departments around the country. All this is against a background of fewer hospital beds, reduced surge capacity and cuts to outpatient services.

This is happening not just in Australia; the escalating healthcare budgets and resource restrictions are also a major issue facing the UK and US.

A great deal of thought is being channeled into this very problem by some clever people. Although I do not consider myself one of those, I think I might have an idea which could potentially save the healthcare budget while having no negative impact on the excellent clinical service and quality patient care that we pride ourselves on in this Nation’s emergency departments.

Before congratulating me, I must concede that this solution unfortunately does involve staffing cuts. I can see no alternative course of action to achieve the desired result. Take a look at the graph below and you are sure to identify the solution yourselves.

For more information and an interesting opinion on this subject, I recommend reading the following editorial by David Oliver published in the BMJ last month.

Welcome to the 168th LITFL Review. Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chuck of FOAM.

The Most Fair Dinkum Ripper Beauts of the Week

Those awesome Swedes. Not only do they host an excellent emergency ultrasound conference (SonoSweden), they livestream it free, and then save all the archives for all to see. That’s hours and hours of FREE ultrasound tutorial videos featuring Matt Dawson, Mike Mullin, Vicki Noble, and others. Did I mention everyone’s in a kimono? [SO]

]]>http://lifeinthefastlane.com/litfl-review-168/feed/0The Brightest Flameshttp://lifeinthefastlane.com/brightest-flames/
http://lifeinthefastlane.com/brightest-flames/#commentsMon, 09 Feb 2015 00:00:17 +0000http://lifeinthefastlane.com/?p=124069Debbie Chalmers implores us to look for signs of physician burnout in ourselves and in others, to build resilience and focus on well being and to 'speak up'.

This is a guest post by Deb Chalmers (@ViridescentFrog), who is an optimist, philomath, tuneless singer of 1980’s songs (and random songs about frogs); and also an Intensivist with an interest in education, ethics & sustainability. It was originally written for the RACP Training Wheels newsletter for physician trainees.

We doctors spend a great deal of effort and energy on the wellbeing of others. All the way through medical school we learn lists of signs and symptoms of disease. We categorize and compartmentalize. We weigh up probabilities. We apply diagnoses. We recognize patterns.

We recognize patterns in others but we seldom recognize patterns in ourselves. And fundamentally we are very good at hiding signs of perceived weakness. Our own mental patterns. Our very personal signs of stress. Medical school taught us to maintain a “healthy emotional distance” from our patients. We had to. We were young and unaccustomed to death and disease. I’m sure you all remember the first time you had to tell someone they were dying. I know I do. But in that process of developing our resilience, we also developed one of our greatest failings. Hiding our emotions from ourselves.

We are taught to speak up in stressful situations at work where we have the best interests of our patients at heart. In the middle of an arrest, if the team leader is not considering the T for Tamponade and it becomes obvious to you… you speak up. You are encouraged to speak up. Crisis resource management mandates that you speak up. As you advance in your training you are encouraged to question, and given the skills and the courage to speak up. To protect your patient. What about speaking up when you see warning signs in your friends? Your colleagues? Do you have the courage to act when you see the signs in yourself?

We are taught to be wary. To HALT. To take care when we are Hungry, Angry, Late or Tired. For the sake of our patients. But do we really HALT. Do we really identify the warning signs in ourselves that we are under strain? Do we identify them in others? And do we speak up when we do?

Take a moment. Ask yourself: Are you emotionally exhausted? Are you drained at the end of the day? Do you feel like there is often no point to what you do? Do you depersonalize your patients? Are you cynical and sarcastic? Extreme examples, but I’m sure we have all been there… at least a little … and then we go on holiday… and it gets better… sometimes?

I implore you to take this opportunity to take stock of your life. To take stock of what is important. To forget the hamster wheel of training reports and run descriptions and the various other TLAs that make up our world. I implore you to consider what you will do when the race is run. When you have the elusive 5 letters that you are currently chasing. What state will you be in at the finish line? Take the time. See the warning signs. Obtain the skills to deal with the stuff that they didn’t teach us about at med school or in our training programs. The stuff of life.

We are good at gaining skills. We couldn’t put in an IV line. And now we can. We couldn’t do that thing, that practical thing that the more senior doctors could do. And now we can. So treat this like any other thing that you need to learn. To master. Find a course. Learn some skills. Look into your own wellbeing for a change. Attend a trainees day. Talk to colleagues. About the stuff that matters. Read a book on wellbeing – there are hundreds out there. Learn to meditate. Learn to do pottery, or horse riding, or whatever. Find stuff that fills your life (your actual life and not your medical life) with joy and happiness.

Because the race is soon over. The letters will be gathered. The graduation ceremony attended. The grown up job obtained.

I recently lost a colleague. A friend. And I miss her. Lots.

I don’t have all the answers. I don’t even listen to my own advice all of the time. But I do try. Every day I try. I try to remember the person that I am, that I want to be. And that person is distinct from the job that I do.

It is only through building our own resilience that we are truly able to help others.